Matthew J. Commers

The Ecological Approach in Health Promotion Programs: A Decade Later

Purpose. Present a 10-year update of the ecologic model of health promotion published by Richard et al. in the American Journal of Health Promotion in 1996. Approach. We adapted and simplified the model by leaving out settings, focusing on levels, and incorporating interpersonal and individual levels and agents that are in control of environmental conditions. Setting. Health care facilities, schools, workplaces, living environments, and public environments were represented in program descriptions. Participants. Forty-three program coordinators responsible for 47 programs were interviewed in the United States and The Netherlands. Methods. A systematic interview protocol elicited general program descriptions and relevant aspects of the ecologic approach. Program aspects from written reports were coded by the authors into levels, interventions, targets, and strategies. Results. The programs had 234 strategies and 276 targets, with a mean of 2.15 levels. Twenty-seven distinct intervention strategies were identified, with the most common being modification of an organization to which the at-risk individuals belong, followed by policy and community changes. Conclusion. Our data fit the ecologic model and our adaptations and indicate that over the past decade health promotion practice may have changed to include more multilevel programs. Systematic analysis of program strategies within and across environmental levels allows better understanding of the social ecology of health-related behavior and potential leverage points for change.

European hospital reforms in times of crisis: Aligning cost containment needs with plans for structural redesign?

Hospitals have become a focal point for health care reform strategies in many European countries during the current financial crisis. It has been called for both, short-term reforms to reduce costs and long-term changes to improve the performance in the long run. On the basis of a literature and document analysis this study analyses how EU member states align short-term and long-term pressures for hospital reforms in times of the financial crisis and assesses the EUs influence on the national reform agenda. The results reveal that there has been an emphasis on cost containment measures rather than embarking on structural redesign of the hospital sector and its position within the broader health care system. The EU influences hospital reform efforts through its enhanced economic framework governance which determines key aspects of the financial context for hospitals in some countries. In addition, the EU health policy agenda which increasingly addresses health system questions stimulates the process of structural hospital reforms by knowledge generation, policy advice and financial incentives. We conclude that successful reforms in such a period would arguably need to address both the organisational and financing sides to hospital care. Moreover, critical to structural reform is a widely held acknowledgement of shortfalls in the current system and belief that new models of hospital care can deliver solutions to overcome these deficits. Advancing the structural redesign of the hospital sector while pressured to contain cost in the short-term is not an easy task and only slowly emerging in Europe.

Determinants of health : theory, understanding, portrayal, policy

Introduction. 1. Toward a Seamless Salutology: Reconciling Subjectivity and Health Professionalism. 2. A Natural Scientific Foundation for Participation and Empowerment: Implications of A Far-From-Equilibrium Thermodynamic Understanding of Health and Health Etiology. 3. Understandings of the Preconditions for and Determinants of Health among Residents of Maastricht, The Netherlands. 4. Indications of Social Variation in Understanding of the Preconditions for and Determinants of Health among Residents of Maastricht, The Netherlands. 5. Representations of Preconditions for and Determinants of Health in the Dutch Press. 6. What Do The Dutch Believe Determines Their Health? 7. Theoretical and Practical Legitimacy of Public Participation in Dutch Health-Related Policy Formulation. 8. Reflections on the Findings: The Dutch Context and Its Relevance. Bibliography. Index.

Shared Decision Making in the Safety Net: Where Do We Go from Here?

Background: Shared decision making (SDM) is an interactive process between clinicians and patients in which both share information, deliberate together, and make clinical decisions. Clinics serving safety net patients face special challenges, including fewer resources and more challenging work environments. The use of SDM within safety net institutions has not been well studied. Methods: We recruited a convenience sample of 15 safety net primary care clinicians (13 physicians, 2 nurse practitioners). Each answered a 9-item SDM questionnaire and participated in a semistructured interview. From the transcribed interviews and questionnaire data, we identified themes and suggestions for introducing SDM into a safety net environment. Results: Clinicians reported only partially fulfilling the central components of SDM (sharing information, deliberating, and decision making). Most clinicians expressed interest in SDM by stating that they “selected a treatment option together” with patients (8 of 15 in strong or complete agreement), but only a minority (3 of 15) “thoroughly weighed the different treatment options” together with patients. Clinicians attributed this gap to many barriers, including time pressure, overwhelming visit content, patient preferences, and lack of available resources. All clinicians believed that lack of time made it difficult to practice SDM. Conclusions: To increase use of SDM in the safety net, efficient SDM interventions designed for this environment, team care, and patient engagement in SDM will need further development. Future studies should focus on adapting SDM to safety net settings and determine whether SDM can reduce health care disparities.

SUPPORTING DECISION MAKING IN CROSS-BORDER REGIONS: A HEALTH TECHNOLOGY ASSESSMENT TOOL FOR HOSPITALS

OBJECTIVES The aim of this study was to develop an health technology assessment (HTA) decision tool to support the decision-making process on health technologies for hospital decision makers in cross-border regions. METHODS Several methods were used to collect information necessary to develop the cross-border mini-HTA decision tool. The literature was inventoried on HTA in border regions and local settings and the use of HTA by local decision makers. Semi-structured interviews with hospital decision makers in cross-border regions were also performed. Based on group discussion of the resulting information, it was decided to use the Danish mini-HTA guideline as a starting point for development of the decision tool. After finishing the first version of the decision tool it was tested in two pilot studies. RESULTS Some questions in the Danish mini-HTA guideline were not relevant. Other questions needed rephrasing and questions about cross-border situations were added. The pilots showed several missing topics, including legal questions and reimbursement issues. The final decision tool consists of three sections: a general section, a section for hospitals not cooperating cross-border and a section for hospitals that are cooperating with hospitals across a national or regional border. CONCLUSIONS Based on our literature search, this may be the first cross-border mini-HTA decision tool. The decision tool will be of help for healthcare professionals and decision makers in border settings who would like to use HTA evidence to support their decision-making process.

Toward best-practice post-disaster mental health promotion for children: Sri Lanka

There is a pressing need for low-cost intervention models to promote mental health among children in the wake of natural disasters. This article describes an evaluation of one such model: the Happy/Sad Letter Box (HSLB) Project, a mental health promotion intervention designed to minimize trauma in children, resulting from the Indian Ocean tsunami of 26 December 2004. The HSLB Project was implemented in 68 schools in Sri Lankas Hambantota District from April 2005 forward. Methods included questionnaires (n = 203), interviews, and group consultation with schoolchildren, teachers, teacher counsellors, principals, educational zone directors and parents. The HSLB intervention was seen as relevant and non-stigmatized, cost-effective if implemented after initial recovery steps, anecdotally effective in identifying and helping resolve trauma, accommodating the full range of childrens daily stressors and sustainable. Gender, childrens age, school size and the level of the tsunami impact for response were found to correlate with response differences. Along four dimensions previously identified in the literature (ability to triage, matching of intervention timing and focus, ability to accommodate a range of stressors and context compatibility), the HSLB Project is a promising intervention model (1) for children; (2) at group-level; (3) relating to natural disasters. The Nairobi Call to Action [WHO (2009) Nairobi Call to Action for Closing the Implementation Gap in Health Promotion. Geneva: World Health Organization] emphasized the importance of mainstreaming health promotion into priority programme areas, specifically including mental health. The HSLB Project represents the integration of health promotion practice into disaster preparedness mental health infrastructure.

Unresolved legal questions in cross-border health care in Europe: liability and data protection

OBJECTIVES Directive 2011/24/EU was designed to clarify the rights of EU citizens in evaluating, accessing and obtaining reimbursement for cross-border care. Based on three regional case studies, the authors attempted to assess the added value of the Directive in helping clarify issues in to two key areas that have been identified as barriers to cross-border care: liability and data protection. STUDY DESIGN Qualitative case study employing secondary data sources including research of jurisprudence, that set up a Legal framework as a base to investigate liability and data protection in the context of cross-border projects. METHODS By means of three case studies that have tackled liability and data protection hurdles in cross-border care implementation, this article attempts to provide insight into legal certainty and uncertainty regarding cross-border care in Europe. RESULTS The case studies reveal that the Directive has not resolved core uncertainties related to liability and data protection issues within cross-border health care. Some issues related to the practice of cross-border health care in Europe have been further clarified by the Directive and some direction has been given to possible solutions for issues connected to liability and data protection. CONCLUSIONS Directive 2011/24/EU is clearly a transposition of existing regulations on data protection and ECJ case law, plus a set of additional, mostly, voluntary rules that might enhance regional border cooperation. Therefore, as shown in the case studies, a practical and case by case approach is still necessary in designing and providing cross-border care.

The European Cross-Border Patient as Both Citizen and Consumer: Public Health and Health System Implications

The aims of this chapter are as follows: To provide a deeper explanation for why the EU patient in cross-border care is not only a consumer but also a citizen, by a more thorough explanation of how and why the EU context is unique. To create a typology of cross-border care that builds on existing ideas but incorporates the dimensions raised above. The analysis of the regulatory history of cross-border care in Europe also raises a number of important policy and political questions. To explore a number of scenarios for the future evolution of cross-border care in the European context. To recommend that a future research agenda monitors the application by the EU members of the Patients’ Rights Directive (2011/24/EU), as well as the monitoring of transnational health care development.

Cross-Border Capacity Assessment in Dementia Care

Within the Euregio Meuse-Rhine, cross-border cooperation in the healthcare sector has taken place on different occasions and at different levels. However, it still proving to be difficult to have an overview of the existing structures and activities of Euregio in specific healthcare fields, such as for instance, dementia care. The aim of this study is to examine to what extent cooperation in the Dutch province of Limburg in the field of dementia care can be considered Euregionally oriented. In order to create more cross-border transparency within the Euregional dementia care field, we conducted a capacity assessment analysis. Capacity assessment is the first step in the further development of healthcare capacities by mapping current as well as desired capacities. Although we related the model as applied in this study explicitly to dementia care in the Euregio Meuse-Rhine, the model could be applicable in other cross-border settings and/or healthcare fields as well. Despite the apparently well-functioning system of regional dementia care networks in the Dutch province of Limburg, none of the respondents declared to have structural contacts with similar organizations in the other (German and Belgian) parts of the Euregio. Moreover, many of our respondents argued that cross-border cooperation in the field of dementia care could be interesting in various ways, but at the same time there is currently no direct necessity to actively pursue such cooperation. Despite the absence of structural cross-border cooperation initiatives in the field of dementia care in the Euregio Meuse-Rhine, some suggestions can be made for the formulation of a potential capacity development response on the basis of the results of the capacity assessment as conducted in this study (showing gaps between current and desired capacities). Even if it is subsequently decided not to formulate a concrete capacity development response (for example due to the lack of a mutual objective need amongst organizations to engage in cross-border cooperation), a capacity assessment offers at the least a reflection on an organizations own performance as well as providing transparency between organizations. The main opportunities for the formulation of a capacity development response on a Euregional level in the field of dementia care are related to knowledge development and the creation of partnerships.

Indications of Social Variation in Understandings of the Preconditions for and Determinants of Health among Residents of Maastricht, The Netherlands

“Health” is considered by most Western populations to be a high personal and public priority. In the Netherlands, a majority of people identifies “gezondheid” (health) as the highest priority in life (NIPO, 1995; SCP, 1996), ranking it squarely above partner, family, or faith.